Polis et al. Reproductive Health (2018) 15:114 https://doi.org/10.1186/s12978-018-0561-0

REVIEW Open Access There might be blood: a scoping review on women’s responses to contraceptive- induced menstrual bleeding changes Chelsea B. Polis* , Rubina Hussain and Amanda Berry

Abstract Introduction: Concern about side effects and health issues are common reasons for contraceptive non-use or discontinuation. Contraceptive-induced menstrual bleeding changes (CIMBCs) are linked to these concerns. Research on women’s responses to CIMBCs has not been mapped or summarized in a systematic scoping review. Methods: We conducted a systematic scoping review of data on women’s responses to CIMBCs in peer-reviewed, English-language publications in the last 15 years. Investigator dyads abstracted information from relevant studies on pre-specified and emergent themes using a standardized form. We held an expert consultation to obtain critical input. We provide recommendations for researchers, contraceptive counselors, and product developers. Results: We identified 100 relevant studies. All world regions were represented (except Antarctica), including Africa (11%), the Americas (32%), Asia (7%), Europe (20%), and Oceania (6%). We summarize findings pertinent to five thematic areas: women’s responses to contraceptive-induced non-standard bleeding patterns; CIMBCs influence on non-use, dissatisfaction or discontinuation; conceptual linkages between CIMBCs and health; women’sresponsesto menstrual suppression; and other emergent themes. Women’s preferences for non-monthly bleeding patterns ranged widely, though amenorrhea appears most acceptable in the Americas and Europe. Multiple studies reported CIMBCs as top reasons for contraceptive dissatisfaction and discontinuation; others suggested disruption of regular bleeding patterns was associated with non-use. CIMBCs in some contexts were perceived as linked with a wide range of health concerns; e.g., some women perceived amenorrhea to cause a buildup of “dirty” or “blocked” blood, in turn perceived as causing blood clots, fibroids, emotional disturbances, weight gain, infertility, or death. Multiple studies addressed how CIMBCs (or ) impacted daily activities, including participation in domestic, work, school, sports, or religious life; sexual or emotional relationships; and other domains. Conclusions: Substantial variability exists around how women respond to CIMBCs; these responses are shaped by individual and social influences. Despite variation in responses across contexts and sub-populations, CIMBCs can impact multiple aspects of women’slives.Women’s responses to CIMBCs should be recognized as a key issue in contraceptive research, counseling, and product development, but may be underappreciated, despite likely – and potentially substantial – impacts on contraceptive discontinuation and unmet need for modern contraception. Keywords: Contraception, Menstruation, Menstrual bleeding changes, Contraceptive non-use and discontinuation, Side effects, Health concerns, Amenorrhea

* Correspondence: [email protected] Guttmacher Institute, 125 Maiden Lane, 7th Floor, New York, NY 10038, USA

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Polis et al. Reproductive Health (2018) 15:114 Page 2 of 17

Plain English summary categories, such as self or partner opposition to contracep- Some contraceptive methods cause changes in women’s tive use, inconvenience of use, or other reasons, may be menstrual bleeding patterns. For example, a woman’s intertwined with health or side effect-related concerns. period may become lighter or heavier, longer or shorter, Therefore, it is difficult to estimate the prevalence or im- less regular, or may disappear altogether. Concerns pact of these concerns, or to disentangle which issues are about side effects and health issues – including those re- of greatest concern to women or couples, particularly on a lated to changes to menstrual bleeding patterns – may national scale. limit use of contraceptive methods. However, the re- Furthermore, while certain contraceptive side effects search on how women respond to contraceptive-induced are clinically documented, various contraceptive-induced menstrual bleeding changes (CIMBCs) has not been bodily processes may be interpreted variably by different summarized in a systematic scoping review. We col- individuals. Perceptions of contraceptive-related side ef- lected and summarized the body of evidence on women’s fects may be rooted in personal experience, knowledge responses to CIMBCs in a standardized manner. We of others’ experiences, or misinformation [9, 10]. While identified 100 studies from around the world relevant to discordance between documented and perceived side ef- this issue. We summarized what studies found regarding fects is acknowledged in the literature [11, 12], both ex- how women respond when contraceptive methods stop perienced and perceived side effects can be highly their periods or cause other non-standard bleeding pat- influential in contraceptive decision-making processes terns, and the extent to which CIMBCs make women [10, 13]. Furthermore, cultural norms and values may unhappy with their method of contraception, or stop shape tolerance (or lack thereof) and fears around vari- their method of contraception, or not use any method of ous side effects. contraception. We also summarized what the evidence Hormonal contraceptive methods and IUDs may in- suggests regarding how women think about CIMBCs in duce changes in menstrual bleeding patterns [14–16], terms of their own health, as well as other themes that which can impact willingness to try or continue using emerged from our review of studies. While women these methods, or method satisfaction [6, 17–23]. across countries and populations respond differently to Contraceptive-induced menstrual bleeding changes different CIMBCs, due to individual and social influ- (CIMBCs) may include bleeding patterns which are pre- ences, it is clear that CIMBCs impact many areas of dictable but diverge from a “typical” menstrual pattern women’s lives. It is important that researchers, medical (such as amenorrhea, commonly induced by methods providers, and contraceptive product developers such as progestin-only injectables, or heavy, prolonged recognize this as an important issue, and we offer rec- bleeding often experienced by copper IUD users [24, 25]), ommendations on how to do so. or may cause unpredictable bleeding patterns. While men- strual bleeding can be measured in straightforward clinical Background categories, there may be large ranges defined around nor- About 99 million unintended pregnancies occur annu- mal menstruation [26, 27] and these clinical definitions ally, the majority of which could be prevented through may not be in line with women’s perceptions of normal use of modern contraception [1, 2]. Concerns about side bleeding. Furthermore, women may experience CIMBCs effects and health issues are common reasons for they consider abnormal or unacceptable, but may still non-use or discontinuation of contraception among clinically fall within the range of normal. women who do not desire pregnancy [3–5]. Among In addition to inconvenience (for unpredictable bleed- married women with an unmet need for contraception ing patterns in particular), and the menstrual hygiene in 52 developing countries, 7–53% reported not using a management costs of many bleeding patterns, some in- method due to these concerns [3]. Some smaller (often dividuals may perceive changes to bleeding patterns as qualitative) studies report on women’s experiences with being tied to overall notions about their health [23, 28, 29] or fears about side effects or health concerns in relation or to physical or mental health issues [6, 9, 10, 12, to various contraceptive methods, but few large or 13, 20, 23, 29]. For example, some women fear that nationally-representative studies specifically investigate injectable-induced amenorrhea leads to permanent in- these issues in detail [6]. Some large-scale surveys (e.g., fertility, which is not supported in the literature [30]. PMA2020 and Demographic and Health Surveys (DHS)) Counseling may not always be comprehensive enough ask about reasons for contraceptive non-use and discon- to adequately prepare women to fully understand, an- tinuation, and include health concerns, fear of side ef- ticipate, or manage CIMBCs [31]. Though difficult to fects, and interference with bodily processes as broad precisely quantify (owing in part to lack of sufficiently response categories, but neither survey asks which spe- specific nationally representative data, as described cific side effects or health concerns led to non-use or above), some evidence suggests that CIMBCs are a discontinuation [7, 8]. Furthermore, other broad response central aspect of what women mean when they report Polis et al. Reproductive Health (2018) 15:114 Page 3 of 17

“side effects” or “health concerns” [32–35], and may among women of reproductive age in any country, pub- be an important reason for non-use or discontinu- lished in peer-reviewed journals within the last 15 years ation. However, the importance of CIMBCs may be (since norms may change over time) [39]. We searched underappreciated in the reproductive health field as a PubMed using Medical Subject Headings (MeSH terms) key contributor to issues such as unmet need for as follows: (“Menstruation/psychology”[MeSH Terms] modern contraception. OR (“Contraceptive Agents, Female”[MeSH Terms] In sum, side effects constitute a major reason for AND (“menstruation”[MeSH Terms] OR “Menstruation contraceptive non-use and discontinuation, and CIMBCs Disturbances”[MeSH Terms] OR “Metrorrhagia”[MeSH are linked, in both real and perceived ways, with a range Terms]))) AND ((“2002/01/01”[PDAT]: “2017/03/14”[PDAT]) of concerns. Differences exist between what bleeding AND “humans”[MeSH Terms] AND English[lang] AND patterns a woman prefers (including the potential for no “female”[MeSH Terms]). We also reviewed reference bleeding changes) and what she is willing to tolerate in lists of included studies and consulted with topical exchange for the benefits of the contraceptive options experts to identify any additional uncaptured studies. available to her [36]. Understanding women’s responses We did not search the grey literature. (including attitudes and behaviors) to experienced or an- ticipated CIMBCs has significant implications for Inclusion criteria current contraceptive use patterns and for the develop- To maximize comprehensiveness and feasibility, while ment of future products, including contraceptives and minimizing inclusion of irrelevant or minimally inform- contraceptive-containing multipurpose prevention tech- ative studies, we required that included studies made nologies (MPTs), which are products in development reference to examining women’s responses to CIMBCs that aim to deliver varied combinations of contraception in the title and/or abstract. We excluded studies examin- and prevention from HIV and other STIs. However, to ing CIMBCs without assessing women’s responses to our knowledge, no recent systematic scoping reviews those changes, and those addressing several other nar- have examined the extent and range of research on this row topical areas, including: topic. Thus, we conducted a scoping review to gather and synthesize data on women’s responses to CIMBCs  Studies that did not explicitly examine women’s and to provide recommendations for providers, re- responses with respect to CIMBCs (e.g., studies on searchers, and product developers. attitudes, cultural beliefs, or practices related to menstruation; age of menarche; impacts of factors Methods such as stress on menstrual patterns; menstrual Methodological approach hygiene management; menstrual synchrony; etc.), Scoping reviews are defined as “aformofknowledgesyn-  Studies addressing specific menstrual issues, or thesis that addresses an exploratory research question intersections of menstruation with specific medical aimed at mapping key concepts, types of evidence, and gaps issues (e.g., , pre-menstrual syndrome, in research related to a defined area or field by systematic- oral contraceptive-induced menstrual migraine, ally searching, selecting, and synthesizing existing know- various psychological conditions, etc.) or constructs ledge” [37]. Whereas systematic reviews typically focus on a (e.g., menstruation and body image), well-defined question of interest (for which appropriate  Studies conducted within highly specific sub-populations study designs can be identified in advance), scoping reviews (e.g.,womeninthemilitary,womenwithintellectual are suitable for broader areas of inquiry, for which multiple disabilities), or studies pertinent to methods of study designs may be relevant [38]. Women’s responses to contraception that are not typically used as ongoing anticipated or experienced CIMBCs have been assessed in methods (e.g., emergency contraception), clinical trials, surveys, qualitative studies, and other designs.  Clinical guidance or reviews, or counseling/prescribing We aimed to systematically search the literature for rele- habits of physicians (e.g., as it relates to medically vant content, to organize this information by summarizing induced amenorrhea). the research questions addressed and articulating key themes, and to identify gaps in the existing literature. While Study screening and data abstraction we refer to countries in which studies were conducted, One author (CBP) conducted the initial title/abstract most studies were not nationally representative, so findings screening using Covidence (advancing abstracts to are not necessarily nationally generalizable. full-text review in the event of uncertainty) [40], and two investigators (dyads of CBP, RH, and/or AB) read Search strategy remaining full texts to determine inclusion and abstract We sought to identify peer-reviewed, English-language data. We developed an abstraction form and pilot tested it publications focused on women’s responses to CIMBCs on multiple studies to refine it. We collected information Polis et al. Reproductive Health (2018) 15:114 Page 4 of 17

about the study setting, population, and methodology, in- Cross-sectional survey designs were most common cluding whether it assessed a particular contraceptive (32%), followed by longitudinal studies including RCTs method or was non-specific. As scoping reviews generally (30%), qualitative studies (19%), retrospective chart re- do not assess study quality [41], these details were min- views (12%), systematic reviews (6%), and mixed method imal. In addition to examining the geographic distribution studies (1%). Inclusion criteria varied across studies, of identified studies, we extracted information about four though some assessed sub-populations (e.g., women key questions (1–4 below), and additional pertinent choosing or discontinuing a particular contraceptive themes that we mutually identified as emerging from the method, adolescents or young women, women living literature: with HIV, etc.) Some studies did not limit their focus to specific contraceptive methods (31%); the remainder fo- 1. Women’s responses related to contraceptive-induced cused on implants (23%), IUDs (12%), OCPs (14%), in- amenorrhea or other non-standard bleeding jectables (4%), the vaginal ring (2%), or multiple specific frequencies methods (14%). 2. CIMBCs as a reason for non-use, discontinuation, CIMBCs as a reason for non-use, discontinuation, and or dissatisfaction dissatisfaction were the most commonly explored 3. Conceptual linkages between CIMBCs and health themes (71 studies), followed by women’s attitudes spe- risks or side effects cifically towards contraceptive-induced amenorrhea or 4. Use of contraception for deliberate menstrual other non-standard bleeding frequencies (33) and con- suppression ceptual linkages between CIMBCs and health risks and 5. Other emergent themes side effects (33). The use of contraception for menstrual suppression was explored, in varying depth, in 28 stud- Since bleeding changes occurring from menstrual sup- ies. We summarized additional key themes stemming pression are deliberately induced, rather than incidental from 41 studies. to use of the method, we mention these findings only briefly, but incorporate them where relevant to other Women’s responses related to contraceptive-induced themes. Since we excluded studies on highly specific amenorrhea and other non-standard bleeding frequencies sub-populations, our findings regarding attitudes toward Women’s responses varied substantially across individ- menstrual suppression are not representative of specific uals, communities, and regions. In some studies, amen- subpopulations (e.g., women in the military, women with orrhea was primarily viewed negatively [43–50]. In intellectual disabilities) that may have significantly differ- addition to health concerns (detailed below), many ent attitudes toward menstrual suppression. women were generally suspicious of amenorrhea [44], saw it as a disadvantage of hormonal contraception [45–50], and identified menstruation as a natural state Expert consultation of womanhood [44, 45]. More positive views of amenor- To enhance the utility and rigor of our review [37, 38, 42], rhea emerged in some studies [48–54], mainly centering we discussed our preliminary findings in a consultation around convenience [44, 50, 51, 55] or avoidance of with five experts on contraceptive acceptability, clinical or menstruation-associated problems (e.g., painful pe- social research on CIMBCs, clinical contraceptive riods) [47, 55]. provision, and contraceptive and/or MPT product devel- Across included surveys, women’s preference for opment. We obtained feedback on our overall approach, amenorrhea ranged between 0% [56] (in Tunisia) and our literature search methods, presentation of results, and 65% [57] (in Brazil) (Table 2)[53, 55–71]. Preferences how to make the paper most useful for providers, re- for regular, non-monthly menstrual cycles (i.e., various searchers, and product developers. durations of longer than one month but less than one year) ranged between 0% [56] (in Indonesia) and 66% Results [68] (in Mexico). Generally, amenorrhea appears more Overview of included studies commonly preferred in North America, Europe and Of 1164 references identified, 100 were considered South America, whereas trends for other bleeding pat- appropriate for inclusion (Fig. 1). All geographic tern preferences are less prominent (Table 2). It is im- world regions were represented (except Antarctica), portant to note that over half of studies examining including studies in Africa (11%), the Americas (32%), women’s bleeding pattern preferences were conducted in Asia (7%), Europe (20%), and Oceania (6%) (Table 1). North America or Europe, and that these findings may The remaining studies (24%) were multi-country stud- not generalize to other contexts. ies or systematic reviews. Publication dates ranged Variation between studies (i.e., age, contraceptive his- from 2002 to 2016. tory, relationship status, race/ethnicity, education, etc.) Polis et al. Reproductive Health (2018) 15:114 Page 5 of 17

1164 references imported for 8 duplicates removed screening

1156 studies screened 1036 studies irrelevant

120 studies assessed for full-text 20 studies excluded eligibility

100 studies included

Fig. 1 Study flowchart precludes disentangling the impact of each factor on black women (9%); reported a preference for amenorrhea women’s preferences, but some relationships were spe- over other bleeding patterns [55]. Other studies examined cifically assessed in individual studies. Greater preference whether relationships existed between preference for for amenorrhea was generally observed in either the amenorrhea (or other non-monthly bleeding patterns) and youngest [44, 55, 71] or the oldest groups of women sur- factors such as occupation [56, 63], parity and desire for veyed [50, 64, 66, 69, 70, 72], while women in middle more children [55, 66], religiosity [44, 55, 56, 64, 65], and age categories (i.e., 24–34) appeared less accepting of women’s current bleeding characteristics [55, 58, 65, 73]; amenorrhea [53, 60]. In contrast, no significant differ- findings for each relationship varied by context, and in ences in preference for amenorrhea by age group were some cases, showed significant associations in different found in studies in Nigeria, South Africa, Scotland, Italy directions. [55, 67]. Younger women were also generally more likely Some studies assessed preferences regarding menstrual to desire less frequent (but non-amenorrheic) menstrual regularity and flow (vs. bleeding intervals). Bleeding re- bleeding patterns [56, 60, 66, 68, 70]. A Swiss study gularity and predictability emerged as a key preference found that while 37% of women preferred monthly in two multi-country studies [70, 74], while another bleeding, nearly as many (32%) preferred an interval of multi-country study found that 58% women would 2–6 months, with women aged 15–19 most likely to pre- accept temporary irregularity if it ultimately led to fewer fer two-monthly intervals [53]. Italian women reported bleeding episodes or amenorrhea over time (ranging no significant differences in preferences for other bleed- from 34% of women in Russia to 76% of women in ing pattern lengths by age [67]. Brazil) [72]. Lighter menstruation was viewed as a Three multi-country analyses showed that previous contraceptive benefit in some studies [54, 58, 75]. use of hormonal contraception was associated with in- creased willingness to consider non-standard bleeding patterns [56, 70, 73], though this was not observed in CIMBCs as a reason for non-use, dissatisfaction, or two European studies [66, 69]. Six studies in various re- discontinuation gions described less interest in non-standard bleeding Seventy-one included studies assessed women’sdiscon- patterns among married or cohabitating women (as tinuation, dissatisfaction, or non-use of contraception due compared with unmarried, non-cohabitating, or divorced to experience or perception of CIMBCs (Additional file 1) women) [56, 58, 64]. In the United States, black and/or [43–50, 52–54, 72, 74–132]. Most pertained to a specific Hispanic women were most likely to believe monthly contraceptive method (implants: 20, IUDs: 12, combined menstruation is necessary [61]. In one study, white OCPs: 10, progestin-only and combined injectables: 4, va- women reported being more open to amenorrhea than ginal ring: 2), while 13 addressed multiple methods and 10 black women (49% vs. 29%), though authors noted a cor- were not method-specific. While bleeding changes may relation between race and study site, preventing the dif- have been inconsistently defined (by researchers and study ferentiation of racial and regional differences [58]. In a participants) across studies, spotting, unpredictable, fre- South African study, more white women (29%) than quent or irregular bleeding were defined as negative side Polis et al. Reproductive Health (2018) 15:114 Page 6 of 17

Table 1 Geographic representation of included studies N % of included studies Countries represented (and number of References across and within studies within that country) subregions Africa 11 11% Northern Africa 1 9% Egypt (1) [115] Eastern Africa 2 18% Kenya (2) [107, 132] Middle Africa 0 0% –– Southern Africa 2 18% South Africa (2) [47, 122] Western Africa 6 55% Nigeria (3), Mali (1), Ghana (2) [43, 76, 87, 94, 102, 104] Americas 32 32% Latin America and the 10 31% Dominican Republic (1), Mexico (3), Brazil (6) [44, 57, 68, 78, 81, 84, 95, 103, 124, Caribbean 137] Northern America 22 69% US (18), Canada (3), Unspecified (1) [46, 58, 59, 61, 62, 71, 75, 85, 86, 90–92, 111, 112, 125–127, 130, 133–136] Antarctica 0 na –– Asia 7 7% Central Asia 0 0% –– Eastern Asia 1 14% China (1) [64] Southeastern Asia 1 14% Thailand (1) [114] Southern Asia 3 43% India (1), Bangladesh (1), Iran (1) [63, 83, 99] Western Asia 2 29% Turkey (2) [45, 123] Europe 20 20% Eastern Europe 0 0% –– Northern Europe 10 50% Finland (1), Ireland (1), Netherlands (1), UK (7) [51, 52, 82, 97, 98, 100, 105, 109, 113, 145] Southern Europe 6 30% Italy (3), Spain (3) [66, 67, 77, 79, 88, 138] Western Europe 4 20% Austria (2), Germany (1), Switzerland (1) [48, 53, 60, 110] Oceania 6 6% Australia and New 6 100% Australia (5), New Zealand (1) [54, 96, 106, 121, 139, 141] Zealand Melanesia, Micronesia, 00% – Polynesia Multi-country studies or 24 24% Australia, Austria, Belgium, Brazil, Canada, [49, 50, 55, 56, 65, 69, 70, 72–74, systematic reviews Chile, China, Czech Republic, Dominican 80, 89, 93, 101, 108, 116–120, 128, Republic, Finland, France, Germany, Hungary, 131, 140, 160] Indonesia, Israel, Italy, Japan, Kenya, Netherlands, New Zealand, Nigeria, Norway, Poland, Russia, Scotland, Slovakia, South Africa, Spain, Sweden, Switzerland, Thailand, Tunisia, Turkey, Ukraine, UK, US, Zimbabwe; unspecified countries in Europe, Asia, and Western Europe; countries included in studies in systematic reviews

effects in 42 studies [43, 48–50, 52–54, 72, 75, 77, 78, 81, 48–50, 76, 78, 79, 84, 86, 90, 91, 98, 100–102, 106, 113, 82, 84, 86, 88–92, 94, 97, 98, 100, 102, 105, 106, 108–111, 115, 123]. 116–119, 122, 123, 127–129, 132], 22 studies noted that heavy or prolonged bleeding were poorly tolerated [49, 53, Non-use 54, 77, 83, 84, 91, 92, 98, 101, 103, 104, 106, 110, 111, Ten studies (including seven qualitative studies) exam- 113–115, 123, 129, 131], and 22 studies found ined whether CIMBCs caused women to hesitate or de- contraceptive-induced amenorrhea to be problematic [44, cide not to use contraception [43, 45–47, 49, 74, 82, 87, Polis Table 2 Studies presenting women’s preferences for amenorrhea or other bleeding patterns by percentage of women

Region of study Country of study Author Publication Year Study Population Percentage of Women Preferring bleeding patterns Health Reproductive al. et Amenorrhea/Never Other than monthly Monthly Bleeding Bleeding bleeding or amenorrhea (ranging from 2 months to 1 year) Africa Nigeria Glasier 2003 Aged 20+ Sagamu: 13% Sagamu: 12% Sagamu: 71% South Africa Glasier 2003 Aged 20+ Cape Town: 9–36%a Cape Town: 15–27%a Cape Town: 30–49%a Tunisia d’Arcangues 2011 Aged 18–38 Tunis: 0% Tunis: 5% Tunis: 95% (2018)15:114 Norplant users Americas Brazil Snow 2007 Aged 18–49 ~ 33%b ~37%b ~ 25%b Brazil Makuch 2012 Aged 18–39 65.3% 18.2% 13.5% Brazil Szarewski 2012 Aged 15–49c 16% 55% n/a Canada Nguyen 2011 Ages not specified 56%b n/a n/a Canada Szarewski 2012 Aged 15–49c 15% 38% n/a Chile d’Arcangues 2011 Aged 18–38 Santiago: 40% Santiago: 13% Santiago: 47% Norplant users Dominican Republic d’Arcangues 2011 Aged 18–38 Santo Domingo: 14% Santo Domingo: 2% Santo Domingo: 84% Norplant users Mexico Marvan 2009 Aged 20–25 and 40–50 n/a 66% 34% Women aged 20–25 were college students United States Andrist 2004 Aged 18–40 59% n/a (Contraception) United States Andrist (JAANP) 2004 Aged 18–40 57% n/a United States Edelman 2007 Mean age 27 38% 29% 34% United States Snow 2007 Aged 18–49 ~ 33%b ~45%b ~ 16%b United States Szarewski 2012 Aged 15–49c 16% 49% n/a United States Lakehomer 2013 Mean age 21.4 28% 65% n/a College students Recent or current contraceptive use Asia China Glasier 2003 Aged 20+ Hong Kong: 6% Hong Kong: 39% Hong Kong: 42% Shanghai: 15% Shanghai: 30% Shanghai: 43% China Ng 2008 Aged 18–49 5% n/a 70% China d’Arcangues 2011 Aged 18–38 Beijing: 4.6% Beijing: 10.7% Beijing: 84.7%

Norplant users 17 of 7 Page India Bhatt 2005 Ages not specified 10–20%d 20–60%d 20–70%d Indonesia d’Arcangues 2011 Aged 18–38 Jakarta: 5.0% Jakarta: 0% Jakarta: 95% Norplant users Table 2 Studies presenting women’s preferences for amenorrhea or other bleeding patterns by percentage of women (Continued) Polis

Region of study Country of study Author Publication Year Study Population Percentage of Women Preferring bleeding patterns Health Reproductive al. et Amenorrhea/Never Other than monthly Monthly Bleeding Bleeding bleeding or amenorrhea (ranging from 2 months to 1 year) Europe Austria Nappi 2016 Aged 18–45 32–34%e 27–31%e 37–39%e Belgium Nappi 2016 Aged 18–45 33–54%e 15–30%e 31–37%e Czech Republic Szarewski 2012 Aged 15–49c 17% 46% n/a (2018)15:114 France Szarewski 2012 Aged 15–49c 17% 38% n/a France Nappi 2016 Aged 18–45 38–53%e 15–19%e 32–43%e Germany Wiegratz 2004 Aged 15–19, 25–34, Women aged 15–57: Women aged 15–57: Women aged 15–57: 45–49, and 52–57 48%b 18%b 24%b Women aged 15–49: Women aged 15–49: Women aged 15–49: 41%b 21%b 29%b Germany Snow 2007 Aged 18–49 ~ 8%b ~60%b ~ 30%b Germany Szarewski 2012 Aged 15–49c 19% 42% n/a Italy Ferrero 2006 Mean age 36.6 29% 28% 44% Italy Fruzzetti 2008 Aged 18 to 50 26% 42% 32% Italy Szarewski 2012 Aged 15–49c 4% 42% n/a Italy Nappi 2016 Aged 18–45 17–18%e 30–33%e 49–53%e Poland Nappi 2016 Aged 18–45 14–19%e 37–42%e 44% (no difference between use or nonuse of hormonal contraception) Spain Nappi 2016 Aged 18–45 19–22%e 30–39%e 42–48%e Switzerland Merki-Feld 2014 Aged 15–19, 25–34, 30% 32% 37% and 45–49 United Kingdom Glasier 2003 Aged 20+ Edinburgh: 37% Edinburgh: 20% Edinburgh: 33% United Kingdom Szarewski 2012 Aged 15–49c 19% 52% n/a aRanges by race and ethnicity bPercentages were calculated or estimated from information presented in the articles cExcluded women with no history of contraceptive use that would not consider future use dRanges by occupation and rural vs. urban location eRanges by use or non-use of hormonal contraception ae8o 17 of 8 Page Polis et al. Reproductive Health (2018) 15:114 Page 9 of 17

104, 106]. A cross-sectional study on long-acting revers- bleeding was the most commonly reported problem ible contraception (LARCs) in the UK reported that the (22%) among Irish implant users [105]. A Kenyan study potential for irregular bleeding disincentivized method found 7–8% of IUD and implant users reported that use [82]. A systematic review on LARCs found that their bleeding patterns were not acceptable [132]. A US though various CIMBCs were perceived both positively study of IUD and implant use found that 17–19% of par- and negatively, heavy or irregular bleeding were gener- ticipants disliked heavy or prolonged bleeding while only ally viewed negatively [49]. A large study in eight devel- 5% disliked lighter and decreased bleeding [92]. IUD oped countries among women interested in combined users in Bangladesh most commonly reported heavy hormonal methods found that small proportions (3–5%) bleeding as an unwanted side effect [83]. Spotting be- did not choose the contraceptive pill, ring or patch due tween periods led 12% of hormonal IUD users in the US to the potential for the absence of regular bleeding [74]. to report disliking the method, while another 13% dis- Women in qualitative studies in the US and New Zea- liked the IUD for factors which included other land were concerned about using amenorrhea-inducing bleeding-related reasons [75]. Only 6% of women with methods because it would complicate knowing if they were hormonal IUD experience in Austria indicated that they pregnant [46, 106], or (in New Zealand and Turkey) were “really not satisfied” with their bleeding pattern because they viewed menstruation as normal and healthy [110]. Lastly, a clinical study comparing a standard and [45, 106]. Various health concerns related to CIMBCs tailored use of OCPs (with the assumption of less bleed- (detailed below), also impacted willingness to use contra- ing with tailored regimens), found lighter bleeding to be ception [43, 47, 87]. among the most commonly reported side effect, but sur- prisingly, more women using a tailored regimen were Dissatisfaction dissatisfied with bleeding patterns (3% versus 11%) [109]. Twenty-one studies addressed how CIMBCs impacted method satisfaction [48–50, 52, 53, 75, 76, 83, 84, 88, 90, Switching and discontinuation 92, 97, 99, 105, 107–110, 114, 132]; 13 of these calcu- Sixty studies [44, 47, 48, 50, 52, 54, 72, 75–81, 83–91, lated estimates of bleeding-related reasons for dissatis- 93–103, 105, 107–123, 125–131] reported at least one faction [53, 75, 76, 83, 84, 92, 105, 107–110, 114, 132]. subject discontinuing or switching a contraceptive We did not detect clear patterns in dissatisfaction for method specifically due to bleeding changes, and 40 CIMBCs by geographic area, but several studies showed measured the proportion of subjects doing so [48, 54, that despite dissatisfaction with specific aspects of a 72, 75–81, 83–86, 88, 89, 91, 93–96, 98, 100–102, 105, given method, some women may nonetheless choose to 107–110, 112–115, 121, 123, 125–128, 130]. Several in- continue use. cluded studies (40) found that CIMBCs were either the Various methods induce different bleeding changes leading cause or among the top reasons for discontinu- (i.e., injectables often induce amenorrhea, copper IUDs ation [44, 48, 52, 54, 75–79, 83–87, 89, 91, 94–100, 102, are associated with a temporary increase in heavy bleed- 105, 107, 108, 110, 112, 113, 115, 121–123, 125–129, ing, etc.) [14, 16]. Menstrual abnormalities were the 131]. Three studies reported that between 0 and 10% of most common complaint among women using inject- discontinuers did so due to CIMBCs [81, 112, 114], 9 re- ables in studies in Mexico and Nigeria [76, 84]. Among ported 11–25% [48, 54, 88, 94, 108–110, 128, 130], 13 the 71% of Nigerian progestin-only injectable users who reported 26–50% [75, 77, 78, 80, 84, 89, 101, 102, 105, were dissatisfied with CIMBCs, amenorrhea was the 109, 115, 121, 129] and 15 reported over 50% [54, 76, most commonly disliked change (67% of those dissatis- 79, 83–86, 95, 96, 98, 100, 121, 123, 125, 126]. Detailed fied) [76]. Similar proportions of progestin-only (24%) information on studies assessing discontinuation accord- and combined injectable (Cyclofem) (22%) users in ing to specific contraceptive method is available in Kenya described CIMBCs as their least liked method Additional file 2. characteristic, despite the finding that women using progestin-only injectables were much more likely to ex- Conceptual linkages between CIMBCs and health risks or perience amenorrhea (71% versus 21% in Cyclofem side effects users) [107]. Thirty-three studies had information pertinent to this Among Nestorone implant users in Brazil, Chile and topic, including six in Africa [43, 47, 87, 104, 107, 122], the Dominican Republic, the most common complaints nine in the Americas [44, 46, 57, 103, 133–137], five in were an increase in flow and duration of bleeding, as Asia [45, 63, 64, 83, 114], nine in Europe [51, 52, 60, 67, well as amenorrhea [108]. Similarly, half of method com- 88, 97, 109, 110, 138], two in Oceania [106, 139], and plaints in a retrospective medical chart review among two in multi-country studies [50, 140]. In studies Thai implant users were bleeding-related (prolonged across multiple countries, including Mali, Kenya, bleeding, spotting, and amenorrhea) [114]. Irregular South Africa, Brazil, Spain, the Dominican Republic, Polis et al. Reproductive Health (2018) 15:114 Page 10 of 17

Canada,theUS,andtheUK,regularmenstruation combined injectable (Cyclofem), 71% of DMPA users wasviewedbymanywomenasamarkerofhealth and 12% of Cyclofem users were amenorrheic by and fertility, as well as providing reassurance of not 12 months. 78% of women in both groups said what they being pregnant [47, 50, 51, 57, 87, 103, 133–135, 137, liked most about their method was the “lack of side ef- 138]. Women in South Africa, Mali, and Brazil, ado- fects”–suggesting that most did not view amenorrhea lescents in South Africa and the US, rural housewives as a side effect [107]. in India, and poor urban women in Turkey perceived In addition to amenorrhea, health concerns around that menstruation cleansed the body of “dirty blood” heavy or prolonged bleeding emerged across several con- or toxins [44–47, 63, 87, 122]. texts [46, 104, 114]. For example, Bangladeshi women However, associations between menstruation and who discontinued an IUD due to heavy bleeding said health were not uniformly positive. Some women in they felt emotionally and physically unwell, were unable South Africa and Mali perceived menstruation as posi- to participate in various activities, and described being tive but simultaneously dirty, inconvenient, or uncom- in a “bloodless body” [83]. Some also said this evoked fortable [47, 50, 87]. Chinese women reported needing fears about uterine perforation and potential death [83]. to take an average of 3.3 sick days from work per year Some Malian woman also linked heavy bleeding to the due to painful menstruation [64]. A higher percentage of possibility of death, or other health issues such as cancer Spanish women in one survey reported not liking any- [87]. Similarly, among some women in the UK, pro- thing about menstruation other than feeling it was nat- longed or heavy bleeding signified bodily damage or a ural and healthy [138]. Some CIMBCs were perceived as “body out of control” [51, 97]. beneficial, for example, in Spain and Austria, women ini- A key theme, generally related to amenorrhea but tiating LNG-IUD use reported appreciating reductions sometimes to excessive bleeding, pertained to fears of in and painful periods [88, 110]. becoming permanently infertile [46, 87]. For example, in For some South African women, living with HIV raised South Africa, some women perceived that “blocked” anxieties about the need to protect family members from blood (amenorrhea) would cause the womb to “get tired” items soiled by their blood, as well as fears that not or that excessive bleeding would lead to infertility menstruating might “keep the HIV inside” of their bodies [47, 122]. In Turkey, some women described fears [47, 50]. In a multi-country study among women living that using contraception would cause their ovaries to with HIV the proportion who perceived amenorrhea as an get “lazy” [45]. However, some infertility fears were ideal feature in a contraceptive method was generally low: linked to the hormonal content of some contracep- 28% in Kenya, 22% in South Africa, and 0% in Brazil [50]. tives, rather than to bleeding changes [50]. Contraceptive-induced amenorrhea raised health-related Ten studies, primarily from higher-income countries, concerns in several settings. Young Malian women viewed provided information specifically pertinent to how women amenorrhea as abnormal or indicative of illness [87]. perceive use of menstrual suppression in relation to health Multiple study participants inSouthAfricaandGhana,as concerns [44, 52, 60, 67, 109, 133, 135, 136, 139, 140]. The well as adolescents in the US, noted perceiving amenorrhea largest of these was an online survey of over 4000 women as “blocked” blood, and believed that if this blood did not across eight countries (Brazil, Canada, the Czech Republic, exit the body, health issues (or even death) might ensue France, Germany, Italy, the UK, and the US) [140]. Health [43, 46, 47, 122]. Some South African adolescents also per- concerns were substantial for women with respect to ceived that “blocked” blood eventually coming out too menstrual suppression, with 42% of women believing that quickly could also lead to death [122]. A range of symp- postponing monthly bleeding would have negative effects toms were understood as being caused by amenorrhea, in- on their health [140]. cluding nosebleeds, blood clots, fibroids, bad skin, anorexia, weight gain, and more [44, 47, 104, 122]. Women’s responses to deliberate menstrual suppression Among adolescents in the US, amenorrhea (and ir- Menstrual suppression involves using certain types of hor- regular bleeding) also caused doubts about the effective- monal contraception in specific ways to deliberately avoid ness of their contraceptive method, and accompanying monthly bleeding, either on a short-term basis for specific fears about being pregnant [46]. life events (i.e., travel, honeymoon, athletic events, etc.) or However, contraceptive-induced amenorrhea was not on a longer-term basis to suppress menstruation for lon- consistently perceived negatively. For example, some ger timeframes. Among 28 studies on menstrual suppres- young abortion patients in New Zealand felt that it had sion [44, 51–53, 57, 59–62, 64, 66–68, 70, 78, 93, 103, 109, both positive and negative aspects [106], and some stu- 111, 127, 133–136, 138–141], many themes were similar dents in India preferred it, so long as it didn’t interfere to those described above, and when relevant, these studies with their feminine looks [63]. In a Kenyan randomized are included in sections above. Given this, and since men- trial comparing a progestin-only injectable (DMPA) to a strual suppression represents the deliberate manipulation Polis et al. Reproductive Health (2018) 15:114 Page 11 of 17

of the menstrual cycle (rather than as a “consequence” of women felt menstrual bleeding had a severe negative im- standard contraceptive use, the main focus of this review), pact on their daily life, and most preferred to reduce we address this topic only briefly. bleeding frequency [70]. The majority of studies focused on suppression A related body of evidence measured favorable and through OCP use [57, 59–61, 66, 68, 70, 93, 103, 109, unfavorable attitudes towards menstruation and associ- 111, 133–136, 138–141], with 6 to 65% of study par- ated factors [51, 53, 55, 58, 60, 62, 65, 68, 70, 103, 137]. ticipants reporting having suppressed menstruation For example, 62% of women in a Brazilian study [137] [57, 59–61, 66, 68, 70, 133–136, 138–141]. Some and 69% of women in a US study [58] noted disliking studies discuss other hormonal methods [66, 78, 139]or menstruation. Inconvenience and pain were common use of to suppress menstruation [139]. reasons [51, 58, 60, 65, 137], while feeling healthy, nat- Other considerations related to menstrual suppression in- ural, womanly, or being reassured of not being preg- cluded: practicality and convenience of avoiding menstru- nant were common themes for liking menstruation ation [52, 59, 135, 139–141], fertility concerns [60, 61, 67, [45, 51, 55, 58, 60, 103, 137]. 134, 136, 139], perceptions of short and long term health Providing information on potential or expected side ef- effects [44, 51, 60, 61, 64, 67, 134, 136, 139, 140], cost of fects, including CIMBCs, is a recommended component menstrual suppression [134] and feminine hygiene prod- of comprehensive contraceptive counseling [143, 144]. ucts [52, 135], impact of menstruation on activities [51, While several studies indicated that at least some partic- 59, 64, 66, 70, 135], management of pain, heavy bleeding ipants received some contraceptive counseling (prior to or other undesirable menstrual symptoms [51, 53, 59, 60, or during method use) on CIMBCs [45, 48, 72, 75, 87, 62, 135, 136, 141], concerns about becoming pregnant 97, 98, 103, 113–115, 123, 124, 145] our search strategy while suppressing menstruation [52, 60, 140], and infor- identified few studies measuring the impact of counsel- mation from or recommendation of a medical provider ing on method satisfaction or continuation. A few stud- about menstrual suppression [57, 59, 61, 138]. ies suggested that good contraceptive counseling may have improved method satisfaction or continuation Other emergent themes rates, but none reported specific results to this effect Several additional themes emerged. For example, multiple [75, 103]. A study among LARC users in Brazil found no studies addressed how CIMBCs (or menstruation) posi- significant difference in discontinuation rates among tively or negatively impacted daily activities, including par- women receiving “routine” versus “intensive” counseling ticipation in domestic, work, school, sports, social, or including CIMBCs [124]. General family planning coun- religious life; sexual or emotional relationships; concentra- seling (which may not have included appropriate tion or sleeping ability; or clothing choices and the need bleeding-specific information) had no overall effect on to manage excessive amounts of laundry (to wash fabrics discontinuation rates of IUD, implants and injectables used to absorb blood) [44, 50, 51, 56, 57, 63, 64, 66, 69, 70, among Egyptian women [115]. Among the implant users 83, 87, 133, 137]. Bangladeshi women who discontinued in the study, however, those experiencing longer bleed- IUD use due to perceived excessive menstrual bleeding ing lengths had a 2% increased hazards of discontinu- described guilt for being unable while bleeding to pray or ation without counseling, and an 18% increased hazards contribute to household tasks (e.g., tending cows or cook- of discontinuation with counseling; this seemingly coun- ing) [83]. Some Indian women appreciated bleeding as it terintuitive result might relate to lack of adequate, provided temporary relief from domestic chores [63], and method-specific counseling [115]. Also surprisingly, in Brazil, an acceptable excuse to refuse sexual intercourse Dutch women specifically counseled on CIMBCs had [44]. Several Malian women described how excessive lower 12- and 24-month implant continuation rates (72 bleeding increases concern that male partners may seek and 53%, respectively) than previous similar studies extramarital partnerships, as men are discouraged from [113]. Only one study included information about partic- sex with menstruating women [87]. In this context, ipants’ assessment of the quality of counseling they re- non-pregnant amenorrheic women may be perceived as ceived on CIMBCs [75]. promiscuous, which can lead to social ostracization and Some studies directly explored women’s perceptions of divorce [87]. Given cultural prohibitions around participa- how bleeding patterns impacted their choice of contra- tion in various activities during menstruation, CIMBCs ception [51, 82], including tradeoffs between contracep- can also “out” women attempting to use a method clan- tive effectiveness and CIMBCs [72]. For example, a destinely [87, 106]. Furthermore, many of the studies survey administered in nine countries found that the reflecting these themes were conducted in low-resource percent of women who would consider using one of the settings, where menstrual hygiene products may be less most effective contraceptive methods, even if it were as- accessible [142]. In a multi-country survey across eight sociated with menstrual cycle changes, ranged from 24% largely higher-income countries, nearly one-third of (in Italy) to 53% (in the UK and Brazil) though overall, Polis et al. Reproductive Health (2018) 15:114 Page 12 of 17

younger women were less likely to consider this tradeoff proportion of relevant studies come from Europe, [72]. Overall, 42% of women in that study would con- Northern America, and other higher-income settings, so sider using one of the most effective contraceptive studying these issues in other regions (e.g., Africa, Asia, methods even when informed that their menstrual cycle and Oceania) is particularly needed, as results from would change and may become irregular [72]. Other these contexts may not generalize to lower-income studies examined which component of CIMBCs worried settings. women [115] or the proportion of women who con- This scoping review fills a key gap in the literature by tacted health care providers to discuss bleeding concerns mapping recent data on women’s responses and prefer- [85]. Finally, a few studies addressed impacts of contra- ences to CIMBCs, and follows methodological guidance ception on menstrual-related issues (such as menstrual for conduct of scoping reviews [37]. Limitations of this pain) [48, 101, 123], or used vignettes pertaining to review include searching a single database (PubMed) women of different ages, relationships statuses, and life and the challenge of crafting a search strategy that is events, to examine how participants thought through both specific and sensitive to such a broad topic of various scenarios involving CIMBCs [43]. inquiry. We iteratively tested multiple search strategies, hand-searched reference lists of key studies, and con- Conclusions sulted with an expert group to identify additional rele- Substantial variability exists in terms of how women re- vant articles. Crafting clear study inclusion criteria was spond to CIMBCs – including what they prefer and also challenging, given the wide variety of pertinent what they are willing to tolerate – and these responses study designs. To maximize comprehensiveness and are shaped by individual and social influences. For ex- feasibility while minimizing inclusion of irrelevant or ample, women’s stated preferences for amenorrhea minimally informative studies, we required that studies ranged from 0 to 65% across included surveys. reference women’s responses to CIMBCs in the title Contraceptive-induced amenorrhea may be viewed more and/or abstract; this may have influenced which studies positively in certain geographical regions (e.g., the Amer- were included. For example, among studies assessing icas, some European and South American countries; contraceptive discontinuation, if CIMBCs were not a top though little comparative data is available in Africa) and reason (and thus not mentioned in the abstract), inclu- by certain subpopulations (e.g., women younger than 24 sion was less likely, which could mean that other reasons or older than 34). In several multi-country surveys, prior for discontinuation are underrepresented among our in- use of hormonal contraception was associated with cluded studies. However, among included studies, we did greater openness to non-monthly bleeding patterns. attempt, where possible, to determine whether CIMBCs While several included studies suggest that CIMBCs do or other factors were the primary reasons for discontinu- substantially impact contraceptive non-use, dissatisfac- ation (or other outcomes). While scoping reviews are tion, and discontinuation, most studies assessing this intended to broadly map a domain in the literature, fu- domain specifically evaluated discontinuation. Specific ture systematic reviews assessing multiple reasons for menstrual bleeding pattern preferences vary widely contraceptive discontinuation could assess whether this across contexts and sub-populations, but it is clear that approach to study inclusion impacted our findings. CIMBCs can impact multiple aspects of women’s daily Finally, like all scoping reviews, we did not assess under- lives, including health-related perceptions, experiences, lying study quality [38]. and fears, as well as participation in domestic, work, Several recommendations for contraceptive re- school, sports, social, religious, sexual, or other activities searchers, providers, and product developers emerge [146, 147]. Furthermore, several studies suggest that from this review. For example, in large, nationally repre- menstrual regularity (whether as part of normal men- sentative surveys, inclusion of response options more struation or less frequent bleeding patterns) may be per- specific than “side-effects” or “health concerns” pertain- ceived positively [70, 74], and unexpected bleeding may ing to CIBMCs would enable more precise quantifica- be perceived negatively [43, 46, 48–54, 72, 75, 77, 78, 81, tion of the association of CIMBCs with unmet need for 82, 86, 88–92, 94, 97, 98, 100, 102, 105, 106, 108–111, family planning and contraceptive discontinuation. 114, 116–119, 122, 123, 127–129, 132]. Monthly bleed- Longitudinal studies collecting information on bleeding ing may relate to the reassurance of not being pregnant patterns should adhere to guidelines used to classify [51, 52, 55, 57, 58, 60, 140] and perceptions of continued bleeding patterns, to enhance comparability across stud- fecundity [46, 47, 58, 60, 67, 87, 106, 134, 137, 139]. As ies [26, 148]. Collecting and controlling for key variables such, women’s responses to CIMBCs (and the factors believed to influence responses to CIMBCs (i.e., age, correlated with those responses) should be broadly prior contraceptive use, etc.) could also enhance com- recognized as a key issue in contraceptive research, parability. In addition to disparities in geographic distribu- counseling, and product development. A substantial tion of studies, several overall research gaps remain, Polis et al. Reproductive Health (2018) 15:114 Page 13 of 17

including understanding how women’s knowledge of vari- Development of new contraceptive or MPT products ous physiological processes (i.e., menstruation, contracep- hold promise from a public health perspective [158], but tive mechanisms of action, etc.) impacts responses to actual impact may be inhibited if acceptability (and bleeding patterns; the impact of contraceptive-induced consequently, adherence) is not adequately addressed amenorrhea or irregular bleeding on timing of pregnancy [146, 159]. Studies on responses to CIMBCs within recognition and reproductive options; and linkages regions which would be targeted for rollout of new between CIMBCs and menstrual hygiene management. products may be useful during development stages, in Researchers should adopt a neutral stance when asking order to enhance product acceptability. Furthermore, women about menstrual preferences (e.g., avoid assuming provision of clear information around expected CIMBCs that amenorrhea is viewed positively or negatively), and for new products can help providers assist women to an- should be familiar with the range of instruments which ticipate and manage these changes, and help avoid nega- have been used to investigate women’s responses to vari- tive perceptions from becoming associated with new ous menstrual-related issues (e.g., Menstrual Attitudes products. Ideally, product development will continue to Questionnaire, Menstrual Distress Questionnaire, expand method options to meet diverse women’s ideal Attitudes towards Menstrual Suppression Instrument, contraceptive profiles (including preferred bleeding pat- Inconvenience Due to Women’s Monthly Bleeding terns), so contraceptors are not required to tolerate un- instrument, etc.); consideration of using common, desirable product characteristics in order to use effective standardized measurements across studies may also pregnancy prevention strategies. be valuable. Overall, the importance of how women perceive and Contraceptive providers should take women’s concerns respond to CIMBCs may be currently underappreciated about CIMBCs seriously and address them in a in the reproductive health field, despite likely – and po- non-judgmental manner, as these changes may not be tentially substantial – impacts on key issues such as viewed merely as a minor side effect and, in some cases, contraceptive discontinuation and unmet need for mod- may have profound impacts on multiple aspects of ern contraception. Contraceptive researchers, providers, women’s lives. Given varied views on whether monthly and product developers – in addition to policy-makers, bleeding is necessary for optimal health [135], providers service delivery suppliers, and funders – can use the should also be aware that some individuals may be body of knowledge summarized in this scoping review to skeptical about medical advice regarding what is “safe” better ensure that women and girls have a reliable sup- or “normal”. Future work could help to clarify paradox- ply of contraceptive (and MPT) options that align with ical findings [115] or investigate limited impacts of some their preferences and effectively prevent unintended counseling approaches [149]. Development of a pregnancies and other adverse outcomes. method-specific tool to assist providers in counseling and treatment options around CIMBCs may be useful, Additional files particularly for contraceptive methods that result in variable bleeding patterns in different women [150]. Additional file 1: Summary of studies including information on Similarly, prospectively eliciting individual’s bleeding contraceptive discontinuation, dissatisfaction or nonuse due to bleeding preferences could assist in helping them select a method related side effects. (DOCX 29 kb) most likely to suit their needs, and identification of Additional file 2: CIMBCs and discontinuation by specific method. (DOCX 19 kb) factors that could help predict which side effects (in- cluding specific bleeding changes) a woman might ex- pect to experience when initiating a contraceptive Acknowledgements We are grateful to the individuals who agreed to participate in our expert method may assist providers to better tailor contra- consultation and who provided valuable input and feedback, including (in ceptive counseling [151]. Addressing some women’s alphabetical order by last name): Dr. Diana Blithe, Dr. Jeanne Marrazzo, concerns that menstrual irregularity is associated with re- Dr. Carolina Sales Vieira, Dr. Cynthia Woodsong, and Dr. Bethany Young-Holt. We also thank Dr. Ann Biddlecom and Dr. Gilda Sedgh, Ms. Jesse Boyer, and duced contraceptive effectiveness may be important [46]. Ms. Colette Rose for their feedback on earlier drafts of the manuscript. Finally, providers and contraceptive users should be aware of treatment options for management of unwanted Funding CIMBCs [152–155] (e.g., non-steroidal anti-inflammatory This study was made possible by UK Aid from the UK Government. Additional support was provided by the Guttmacher Center for Population Research drugs, combined oral contraceptive pills, etc.), though Innovation and Dissemination (NIH grant 5 R24 HD074034). The views more research is also needed to refine treatment options expressed are those of the authors and do not necessarily reflect the and improve bleeding patterns and user satisfaction/ positions or policies of the donors. acceptability. Some evidence does suggest that treat- Availability of data and materials ing undesirable CIMBCs may improve contraceptive Data sharing is not applicable to this article as no datasets were generated continuation [156, 157]. or analysed during the current study. Polis et al. Reproductive Health (2018) 15:114 Page 14 of 17

Authors’ contributions 16. National collaborating centre for women’s and children’shealth(UK). CP primarily conceived of the idea for the manuscript and led the literature Long-acting reversible contraception: The effective and appropriate use search. CP, RH, and AB reviewed and abstracted full-text studies, participated of long-acting reversible contraception. 2005. in the expert consultation, and drafted the manuscript. All authors read and 17. Sznajder KK, Tomaszewski KS, Burke AE, Trent M. Incidence of discontinuation approved the final manuscript. of long-acting reversible contraception among adolescent and young adult women served by an urban primary care clinic. J Pediatr Adolesc Gynecol. – Ethics approval and consent to participate 2017;30:53 7. Not applicable. 18. Belsey EM. Regulation TF on L-ASA for F, others. The association between patterns and reasons for discontinuation of contraceptive use. Contraception. 1988;38:207–25. Consent for publication 19. Grant C, Serrani M, Vogtländer K, Parke S, Briggs P. Continuation rates, Not applicable. bleeding profile acceptability, and satisfaction of women using an oral contraceptive pill containing valerate and dienogest versus a Competing interests -only pill after switching from an ethinylestradiol-containing The authors declare that they have no competing interests. pill in a real-life setting: results of the CONTENT study. Int J Womens Health. 2016;8:477–87. 20. Kibira SPS, Muhumuza C, Bukenya JN, Atuyambe LM. “I Spent a Full Month Publisher’sNote Bleeding, I Thought I Was Going to Die…” A Qualitative Study of Experiences Springer Nature remains neutral with regard to jurisdictional claims in of Women Using Modern Contraception in Wakiso District, Uganda. Mintzes B, published maps and institutional affiliations. editor. Plos One. 2015;10:e0141998. 21. Inoue K, Barratt A, Richters J. Does research into contraceptive method Received: 6 February 2018 Accepted: 15 June 2018 discontinuation address women’s own reasons? A critical review. J Fam Plann Reprod Health Care. 2015;41(4):292–9. jfprhc–2014 22. Staveteig S. Fear, opposition, ambivalence, and omission: results from a follow-up study on unmet need for family planning in Ghana. PLoS One. References 2017;12:e0182076. 1. Guttmacher Institute. Adding it up: investing in contraception and maternal 23. Henry R. Contraceptive practice in Quirino province, Philippines: Experiences and newborn health, 2017. New York: Guttmacher Institute; 2017. Available of side effects. 2001 [cited 5 Jan 2017]; Available from: http://dhsprogram. from: https://www.guttmacher.org/sites/default/files/factsheet/adding-it-up- com/publications/publication-QRS1-Qualitative-Research-Studies.cfm contraception-mnh-2017.pdf 2. Bearak J, Popinchalk A, Alkema L, Sedgh G. Global, regional, and subregional 24. Jacobstein R, Polis C. Progestin-only contraception: Injectables and implants. – trends in unintended pregnancy and its outcomes from 1990 to 2014: Best Pr Res Clin Obstet Gynaecol. 2014;28:795 806. estimates from a Bayesian hierarchical model. Lancet Glob Health. 2018;6: 25. Hubacher D, Chen P-L, Park S. Side effects from the copper IUD: do they – e380-389. decrease over time? Contraception. 2009;79:356 62. 3. Sedgh G, Ashford LS, Hussain R. Unmet need for contraception in 26. Fraser I, Critchley H, Broder M, Munro M. The FIGO recommendations on developing countries: examining women’s reasons for not using a method. terminologies and definitions for normal and abnormal uterine bleeding. – The Guttmacher institute; 2016. Available from: http://repositorio.gire.org. Semin Reprod Med. 2011;29:383 90. mx/bitstream/123456789/2049/1/unmet-need-for-contraception-in- 27. Belsey EM, Farley TMM. The analysis of menstrual bleeding patterns: a review. – developing-countries-report.pdf. Appl Stoch Models Bus Ind. 1987;3:125 50. 4. Bradley SEK, Schwandt HM, Khan S. Levels, Trends, and Reasons for 28. Khan R, MacQuarrie KLD, Nahar Q, Sultana M. The men are away: Contraceptive Discontinuation. Calverton, MD: ICF Macro; 2009. Sep. pregnancy risk and family planning needs among women with a Report No.: 20 migrant husband in Barisal, Bangladesh. 2016 [cited 5 Jan 2017]; 5. Sedgh G, Hussain R. Reasons for contraceptive nonuse among women Available from: http://dhsprogram.com/publications/publication-FA98- having unmet need for contraception in developing countries. Stud Fam Further-Analysis.cfm Plan. 2014;45:151–69. 29. Yoder PS, Guèye M, Konaté M. The use of family planning methods in Mali: 6. Williamson LM, Parkes A, Wight D, Petticrew M, Hart GJ. Limits to modern The how and why of taking action. 2011 [cited 5 Jan 2017]; Available from: contraceptive use among young women in developing countries: a systematic http://dhsprogram.com/publications/publication-QRS18-Qualitative-Research- review of qualitative research. Reprod Health. 2009;6:3. Studies.cfm 7. DHS Model Questionnaire - Phase 7 (English, French). [cited 28 Mar 2017]. 30. Mansour D, Gemzell-Danielsson K, Inki P, Jensen JT. Fertility after discontinuation Available from: http://dhsprogram.com/publications/publication-DHSQ7- of contraception: a comprehensive review of the literature. Contraception. 2011; DHS-Questionnaires-and-Manuals.cfm 84:465–77. 8. PMA2020 Data | PMA2020 [Internet]. [cited 28 Mar 2017]. Available from: 31. Dehlendorf C, Levy K, Kelley A, Grumbach K, Steinauer J. Women’s preferences http://pma2020.org/pma2020-data for contraceptive counseling and decision making. Contraception. 2013;88: 9. Diamond-Smith N, Campbell M, Madan S. Misinformation and fear of side-effects 250–6. of family planning. Cult Health Sex. 2012;14:421–33. 32. National Institute of Population Studies (NIPS) [Pakistan], ICF International. 10. Wells E. Countering myths and misperceptions about contraceptives. Seattle, Pakistan Demographic and Health Survey 2012–13. Islamabad, Pakistan and WA: PATH; 2015. p. 1–8. Available from: http://www.path.org/publications/ Calverton, MD: NIPS and ICF International; 2013. detail.php?i=2525 33. Statistics Indonesia (Badan Pusat Statistik–BPS), National Population and 11. Campbell M, Sahin-Hodoglugil NN, Potts M. Barriers to fertility regulation: a Family Planning Board (BKKBN), Kementerian Keschatan (Kemenkes–MOH), review of the literature. Stud Fam Plan. 2006;37:87–98. ICF International. Indonesia Demographic and Health Survey 2012. Jakarta, 12. Morse JE, Rowen TS, Steinauer J, Byamugisha J, Kakaire O. A qualitative assessment Indonesia; 2013 p. 544. of Ugandan women’s perceptions and knowledge of contraception. Int J 34. Bagnan JA T, Aboubakar M, Tognifode V, Lokossou MSHS, Obossou AAA, Gynaecol Obstet Off Organ Int Fed Gynaecol Obstet. 2014;124:30–3. Salifou K, et al. Side Effects of Hormonal Contraception of Patients in the 13. Burke HM, Ambasa-Shisanya C. Qualitative study of reasons for discontinuation Family Planning of Centre University Hospital of Mother and Child Lagoon, of injectable contraceptives among users and salient reference groups in Cotonou (Benin). Gynecol Obstet . 2017 [cited 7 May 2018];07. Available Kenya. Afr J Reprod Health. 2011;15:67–78. from: https://www.omicsonline.org/open-access/side-effects-of-hormonal- 14. Hatcher RA, Trussell J, Nelson AL, Cates, Jr. W, Kowal D, Policar MS. contraception-of-patients-in-the-family-planningof-centre-university-hospital- Contraceptive Technology. 20th ed. Ardent Media; 2012. of-mother-and-child-lagoon-2161-0932-1000452.php?aid=93684 15. López-Picado A, Lapuente O, Lete I. Efficacy and side-effects profile of the 35. Yangsi TT, Florent FY, Ngole ME, Nelson F. Modern contraceptive choice ethinylestradiol and contraceptive vaginal ring: a systematic among patients seen at the "Cameroon National Planning Association for review and meta-analysis. Eur J Contracept Reprod Health Care Off J Eur Family Welfare" Clinic Yaoundé. Clin Med Insights Reprod Health. 2017;11:1- Soc Contracept. 2017;22:131–46. 6.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5484599/. Polis et al. Reproductive Health (2018) 15:114 Page 15 of 17

36. Heise LL. Beyond acceptability: Reorienting research on contraceptive 59. Lakehomer H, Kaplan PF, Wozniak DG, Minson CT. Characteristics of choice. World Health Organisation, beyond acceptability. Users’ perspectives scheduled bleeding manipulation with combined hormonal contraception in on contraception. 1997. pp. 6–13. Geneva: WHO. university students. Contraception. 2013;88:426–30. 37. Colquhoun HL, Levac D, O’Brien KK, Straus S, Tricco AC, Perrier L, et al. Scoping 60. Wiegratz I, Hommel HH, Zimmermann T, Kuhl H. Attitude of German women reviews: time for clarity in definition, methods, and reporting. J Clin Epidemiol. and gynecologists towards long-cycle treatment with oral contraceptives. 2014;67:1291–4. Contraception. 2004;69:37–42. 38. Arksey H, O’Malley L. Scoping studies: towards a methodological framework. 61. Andrist LC, Arias RD, Nucatola D, Kaunitz AM, Musselman BL, Reiter S, et al. Int J Soc Res Methodol. 2005;8:19–32. Women’s and providers’ attitudes toward menstrual suppression with 39. WHO Task Force on Psychosocial Research in Family Planning. A cross-cultural extended use of oral contraceptives. Contraception. 2004;70:359–63. study of menstruation: implications for contraceptive development and use. 62. Andrist LC, Hoyt A, Weinstein D, McGibbon C. The need to bleed: women’s attitudes Stud Fam Plan. 1981;12:3–16. and beliefs about menstrual suppression. J Am Acad Nurse Pract. 2004;16:31–7. 40. Covidence systematic review software. Melbourne: Virtas Health Innovation. 63. Bhatt R, Bhatt M. Perceptions of Indian women regarding menstruation. Int Available from: www.covidence.org J Gynecol Obstet. 2005;88:164–7. 41. Peters MDJ, Godfrey CM, Khalil H, McInerney P, Parker D, Soares CB. 64. Ng QTK, Yuen PM. Preferred frequency of menstruation in Hong Kong Guidance for conducting systematic scoping reviews. Int J Evid Based Chinese women: characteristics andfactors.AsiaPacJPublicHealth. Healthc. 2015;13:141–6. 2008;20(Suppl):189–95. 42. Levac D, Colquhoun H, O’Brien KK. Scoping studies: advancing the 65. Snow R, Hardy E, Kneuper E, Hebling EM, Hall G. Women’s responses to methodology. Implement Sci. 2010;5:69. menses and nonbleeding intervals in the USA, Brazil and Germany. 43. Hindin MJ, McGough LJ, Adanu RM. Misperceptions, misinformation and Contraception. 2007;76:23–9. myths about modern contraceptive use in Ghana. J Fam Plann Reprod 66. Ferrero S, Abbamonte LH, Giordano M, Alessandri F, Anserini P, Remorgida V, Health Care. 2014;40:30–5. et al. What is the desired menstrual frequency of women without menstruation- 44. Estanislau do Amaral MC, Hardy E, Hebling EM, Faúndes A. Menstruation and related symptoms? Contraception. 2006;73:537–41. amenorrhea: opinion of Brazilian women. Contraception. 2005;72:157–61. 67. Fruzzetti F, Paoletti AM, Lombardo M, Carmignani A, Genazzani AR. Attitudes of 45. Ay P, Hidiroglu S, Topuzoglu A, Ucar MS, Kose OO, Save D. Do perceived Italian women concerning suppression of menstruation with oral contraceptives. health risks outweigh the benefits of modern contraceptives? A qualitative Eur J Contracept Reprod Health Care. 2008;13:153–7. study in a suburban population in Istanbul, Turkey. Eur J Contracept Reprod 68. Marván ML, Lama C. Attitudes toward menstrual suppression and conformity Health Care. 2007;12:154–61. to feminine norms in young and middle-aged Mexican women. J Psychosom 46. Clark LR, Barnes-Harper KT, Ginsburg KR, Holmes WC, Schwarz DF. Menstrual Obstet Gynecol. 2009;30:147–55. irregularity from hormonal contraception: a cause of reproductive health 69. Nappi RE, Fiala C, Chabbert-Buffet N, Häusler G, Jamin C, Lete I, et al. concerns in minority adolescent young women. Contraception. 2006;74:214–9. Women’s preferences for menstrual bleeding frequency: results of the 47. Laher F, Todd CS, Stibich MA, Phofa R, Behane X, Mohapi L, et al. Role of inconvenience due to Women’s monthly bleeding (ISY) survey. Eur J menstruation in contraceptive choice among HIV-infected women in Soweto, Contracept Reprod Health Care. 2016;21:242–50. South Africa. Contraception. 2010;81:547–51. 70. Szarewski A, von Stenglin A, Rybowski S. Women’sattitudestowards 48. Baldaszti E, Wimmer-Puchinger B, Löschke K. Acceptability of the long-term monthly bleeding: results of a global population-based survey. Eur J contraceptive levonorgestrel-releasing intrauterine system (Mirena): a 3-year Contracept Reprod Health Care. 2012;17:270–83. follow-up study. Contraception. 2003;67:87–91. 71. Nguyen LN, Jamieson MA. Adolescent users of an online contraception 49. Coombe J, Harris ML, Loxton D. What qualities of long-acting reversible selection tool: how user preferences and characteristics differ from those of contraception do women perceive as desirable or undesirable? A systematic adults. J Pediatr Adolesc Gynecol. 2011;24:317–9. review. Sex Health. 2016;13:404-419. 72. Hooper DJ. Attitudes, awareness, compliance and preferences among 50. Todd CS, Stibich MA, Laher F, Malta MS, Bastos FI, Imbuki K, et al. Influence hormonal contraception users: a global, cross-sectional, self-administered, of culture on contraceptive utilization among HIV-positive women in Brazil, online survey. Clin Drug Investig. 2010;30:749–63. Kenya, and South Africa. AIDS Behav. 2011;15:454–68. 73. Hardy E, Hebling EM, de Sousa MH, Kneuper E, Snow R. Association between 51. Newton VL, Hoggart L. Hormonal contraception and regulation of characteristics of current menses and preference for induced amenorrhea. menstruation: a study of young women’s attitudes towards ‘having a Contraception. 2009;80:266–9. period’. J Fam Plann Reprod Health Care. 2015;41:210–5. 74. Egarter C, Tirri BF, Bitzer J, Kaminskyy V, Oddens BJ, Prilepskaya V, et al. 52. Graham CA, Panicker S, Shawe J, Stephenson J. Women’s experiences with Women’s perceptions and reasons for choosing the pill, patch, or ring in tailored use of a combined oral contraceptive: a qualitative study. Hum the CHOICE study: a cross-sectional survey of contraceptive method selection Reprod. 2013;28:1620–5. after counseling. BMC Womens Health. 2013;13:9. 53. Merki-Feld GS, Breitschmid N, Seifert B, Kreft M. A survey on Swiss women’s 75. Jensen JT, Nelson AL, Costales AC. Subject and clinician experience with the preferred menstrual/withdrawal bleeding pattern over different phases of levonorgestrel-releasing intrauterine system. Contraception. 2008;77:22–9. reproductive life and with use of hormonal contraception. Eur J Contracept 76. Adeyemi A, Adekanle D. Progestogen-only injectable contraceptive: experience Reprod Health Care. 2014;19:266–75. of women in Osogbo, southwestern Nigeria. Ann Afr Med. 2012;11:27. 54. Weisberg E, Bateson D, McGeechan K, Mohapatra L. A three-year 77. Arribas-Mir L, Rueda-Lozano D, Agrela-Cardona M, Cedeño-Benavides T, comparative study of continuation rates, bleeding patterns and satisfaction Olvera-Porcel C, Bueno-Cavanillas A. Insertion and 3-year follow-up experience in Australian women using a subdermal contraceptive implant or of 372 etonogestrel subdermal contraceptive implants by family physicians in progestogen releasing-intrauterine system. Eur J Contracept Reprod Health Granada, Spain. Contraception. 2009;80:457–62. Care. 2014;19:5–14. 78. Barreiros FA, Guazzelli CAF, de Araújo FF, Barbosa R. Bleeding patterns of 55. Glasier AF, Smith KB, van der Spuy ZM, Ho PC, Cheng L, Dada K, et al. women using extended regimens of the contraceptive vaginal ring. Amenorrhea associated with contraception-an international study on Contraception. 2007;75:204–8. acceptability. Contraception. 2003;67:1–8. 79. Bastianelli C, Farris M, Benagiano G. Use of the levonorgestrel-releasing 56. d’Arcangues C, Jackson E, Brache V, Piaggio G & on behalf of the study intrauterine system, quality of life and sexuality. Experience in an Italian group on progestogen-induced vaginal bleeding disturbances. Women’s family planning center. Contraception. 2011;84:402–8. views and experiences of their vaginal bleeding patterns: an international 80. Blumenthal PD, Gemzell-Danielsson K, Marintcheva-Petrova M. Tolerability perspective from Norplant users. Eur J Contracept Reprod Health Care. 2011; and clinical safety of Implanon®. Eur J Contracept Reprod Health Care. 2008; 16:9–17. 13:29–36. 57. Makuch MY, Duarte-Osis MJ, de Pádua KS, Petta C, Bahamondes L. Opinion 81. Bortolotti de Mello Jacobucci MS, Guazzelli CAF, Barbieri M, Araújo FF, and experience of Brazilian women regarding menstrual bleeding and use Moron AF. Bleeding patterns of adolescents using a combination contraceptive of combined oral contraceptives. Int J Gynecol Obstet. 2012;117:5–9. injection for 1 year. Contraception. 2006;73:594–7. 58. Edelman A, Lew R, Cwiak C, Nichols M, Jensen J. Acceptability of contraceptive- 82. Bracken J, Graham CA. Young women’s attitudes towards, and experiences induced amenorrhea in a racially diverse group of US women. Contraception. of, long-acting reversible contraceptives. Eur J Contracept Reprod Health 2007;75:450–3. Care. 2014;19:276–84. Polis et al. Reproductive Health (2018) 15:114 Page 16 of 17

83. Bradley JE, Alam M-E, Shabnam F, Beattie TSH. Blood, men and tears: keeping 109. Stephenson J, Shawe J, Panicker S, Brima N, Copas A, Sauer U, et al. Randomized IUDs in place in Bangladesh. Cult Health Sex. 2009;11:543–58. trial of the effect of tailored versus standard use of the combined oral 84. Canto de Cetina TE, Luna MO, Cetina Canto JA, Bassol S. Menstrual pattern contraceptive pill on continuation rates at 1 year. Contraception. 2013;88:523–31. and lipid profiles during use of medroxyprogesterone acetate and estradiol 110. Stoegerer-Hecher E, Kirchengast S, Huber JC, Hartmann B. Amenorrhea and cypionate and NET-EN (200 mg) as contraceptive injections. Contraception. BMI as independent determinants of patient satisfaction in LNG-IUD users: 2004;69:115–9. cross-sectional study in a central European district. Gynecol Endocrinol. 85. Casey PM, Long ME, Marnach ML, Bury JE. Bleeding related to etonogestrel 2012;28:119–24. subdermal implant in a US population. Contraception. 2011;83:426–30. 111. Sulak PJ, Kuehl TJ, Ortiz M, Shull BL. Acceptance of altering the standard 21- 86. Casey PM, Long ME, Marnach ML, Fleming-Harvey J, Drozdowicz LB, Weaver day/7-day oral contraceptive regimen to delay menses and reduce hormone AL. Association of body mass index with removal of etonogestrel subdermal withdrawal symptoms. Am J Obstet Gynecol. 2002;186:1142–9. implant. Contraception. 2013;87:370–4. 112. Teal SB, Sheeder J. IUD use in adolescent mothers: retention, failure and 87. Castle S. Factors influencing young Malians’ reluctance to use hormonal reasons for discontinuation. Contraception. 2012;85:270–4. contraceptives. Stud Fam Plan. 2003;34:186–99. 113. Teunissen AM, Grimm B, Roumen FJME. Continuation rates of the subdermal 88. Cristobal I, Lete LI, de la VE, Perulero N, Arbat A, Canals I. One year quality of contraceptive Implanon ® and associated influencing factors. Eur J Contracept life measured with SEC-QoL in levonorgestrel 52mg IUS users. Contraception. Reprod Health Care. 2014;19:15–21. 2016;93:367–71. 114. Thamkhantho M, Jivasak-Apimas S, Angsuwathana S, Chiravacharadej G, 89. Darney P, Patel A, Rosen K, Shapiro LS, Kaunitz AM. Safety and efficacy of a Intawong J. One-year assessment of women receiving sub-dermal single-rod etonogestrel implant (Implanon): results from 11 international contraceptive implant at Siriraj family planning clinic. J Med Assoc Thai. clinical trials. Fertil Steril. 2009;91:1646–53. 2008;91:775–80. 90. Dickerson LM, Diaz VA, Jordon J, Davis E, Chirina S, Goddard JA, et al. 115. Tolley E, Loza S, Kafafi L, Cummings S. The impact of menstrual side effects Satisfaction, early removal, and side effects associated with long-acting on contraceptive discontinuation: findings from a longitudinal study in Cairo, reversible contraception. Fam Med. 2013;45:701–7. Egypt. Int Fam Plan Perspect. 2005;31:15–23. 91. Deokar AM, Jackson W, Omar HA. Menstrual bleeding patterns in adolescents 116. Van Vliet HAAM, Grimes DA, Helmerhorst FM, Schulz KF, Lopez LM. Biphasic using etonogestrel (ENG) implant. Int J Adolesc Med Health. 2011;23:75–7. versus monophasic oral contraceptives for contraception. Cochrane 92. Diedrich JT, Desai S, Zhao Q, Secura G, Madden T, Peipert JF. Association of Database Syst Rev. 2006. Issue 3. Art. No.: CD002032. https://doi.org/10. short-term bleeding and cramping patterns with long-acting reversible 1002/14651858.CD002032.pub2. contraceptive method satisfaction. Am J Obstet Gynecol. 2015;212:50.e1–8. 117. Van Vliet HAAM, Grimes DA, Lopez LM, Schulz KF, Helmerhorst FM. Triphasic 93. Edelman A, Micks E, Gallo MF, Jensen JT, Grimes DA. Continuous or versus monophasic oral contraceptives for contraception. Cochrane extended cycle vs. cyclic use of combined hormonal contraceptives for Database Syst Rev. 2011. Issue 11. Art. No.: CD003553. https://doi.org/10. contraception. Cochrane Database Syst Rev. 2014. Issue 7. Art. No.: 1002/14651858.CD003553.pub3. CD004695. https://doi.org/10.1002/14651858.CD004695.pub3. 118. Van Vliet HAAM, Raps M, Lopez LM, Helmerhorst FM. Quadriphasic 94. Ezegwui HU, Ikeako LC, Ishiekwene CIC, Oguanua TC. The discontinuation versusmonophasic oral contraceptives for contraception. Cochrane rate and reasons for discontinuation of implanon at the family planning Database Syst Rev. 2011. Issue 11. Art. No.: CD009038. https://doi.org/10. clinic of University of Nigeria Teaching Hospital (UNTH) Enugu, Nigeria. 1002/14651858.CD009038.pub2. Niger J Med. 2011;20:448–50. 119. Van Vliet HAAM, Grimes DA, Helmerhorst FM, Schulz KF, Lopez LM. Biphasic 95. Flores JBO, Balderas ML, Bonilla MC, Vázquez-Estrada L. Clinical experience versus triphasic oral contraceptives for contraception. Cochrane Database and acceptability of the etonogestrel subdermal contraceptive implant. Int J Syst Rev. 2006. Issue 3. Art. No.: CD003283. https://doi.org/10.1002/ Gynaecol Obstet. 2005;90:228–33. 14651858.CD003283.pub2. 96. Harvey C, Seib C, Lucke J. Continuation rates and reasons for removal among 120. Weisberg E, Brache V, Alvarez F, Massai R, Mishell DR, Apter D, et al. Clinical Implanon® users accessing two family planning clinics in Queensland, Australia. performance and menstrual bleeding patterns with three dosage combinations Contraception. 2009;80:527–32. of a Nestorone® progestogen/ethinyl estradiol contraceptive vaginal ring used on 97. Hoggart L, Newton VL, Dickson J. “I think it depends on the body, with mine it a bleeding-signaled regimen. Contraception. 2005;72:46–52. didn’twork”: explaining young women’s contraceptive implant removal. 121. Wong RC, Bell RJ, Thunuguntla K, McNamee K, Vollenhoven B. Implanon Contraception. 2013;88:636–40. users are less likely to be satisfied with their contraception after 6 months 98. Jeffreys LA, Clark AL. A successful approach to long-acting contraceptive than IUD users. Contraception. 2009;80:452–6. implants in primary care. Contraception. 2012;85:381–3. 122. Wood K, Jewkes R. Blood blockages and scolding nurses: barriers to adolescent 99. Jenabi E, Alizade SM, Baga RI. Continuation rates and reasons for discontinuing contraceptive use in South Africa. Reprod Health Matters. 2006;14:109–18. TCu380A IUD use in Tabriz, Iran. Contraception. 2006;74:483–6. 123. Yildizbas B, Sahin HG, Kolusari A, Zeteroglu S, Kamacı M. Side effects and 100. Lakha F, Glasier AF. Continuation rates of Implanon in the UK: data from an acceptability of Implanon®: a pilot study conducted in eastern Turkey. Eur J observational study in a clinical setting. Contraception. 2006;74:287–9. Contracept Reprod Health Care. 2007;12:248–52. 101. Mansour D, Korver T, Marintcheva-Petrova M, Fraser IS. The effects of Implanon® on 124. Modesto W, Bahamondes MV, Bahamondes L. A randomized clinical trial of menstrual bleeding patterns. Eur J Contracept Reprod Health Care. 2008;13:13–28. the effect of intensive versus non-intensive counselling on discontinuation 102. Mutihir JT, Nyango DD. Indications for removal of etonogestrel implant rates due to bleeding disturbances of three long-acting reversible within two years of use in Jos, Nigeria. East Afr Med J. 2010;87:461–4. contraceptives. Hum Reprod. 2014;29:1393–9. 103. Nanda K, Lendvay A, Kwok C, Tolley E, Dubé K, Brache V. Continuous compared 125. Obijuru L, Bumpus S, Auinger P, Baldwin CD. Etonogestrel implants in with cyclic use of oral contraceptive pills in the Dominican Republic: a adolescents: experience, satisfaction, and continuation. J Adolesc Health. randomized controlled trial. Obstet Gynecol. 2014;123:1012–22. 2016;58:284–9. 104. Osei I, Birungi H, Addico G, Askew I, Gyapong JO. What happened to the 126. Archer DF, Jensen JT, Johnson JV, Borisute H, Grubb GS, Constantine GD. IUD in Ghana? Afr J Reprod Health. 2005;9:76–91. Evaluation of a continuous regimen of levonorgestrel/ethinyl estradiol: 105. Riney S, O’Shea B, Forde A. Etonogestrel implant as a contraceptive choice; phase 3 study results. Contraception. 2006;74:439–45. patient acceptability and adverse effect profile in a general practice setting. 127. Anderson F, Hait H. A multicenter, randomized study of an extended cycle Ir Med J. 2009;102:24–5. oral contraceptive. Contraception. 2003;68:89–96. 106. Rose SB, Cooper AJ, Baker NK, Lawton B. Attitudes toward long-acting 128. Apter D, Briggs P, Tuppurainen M, Grunert J, Lukkari-Lax E, Rybowski S, et al. reversible contraception among young women seeking abortion. J Women's A 12-month multicenter, randomized study comparing the levonorgestrel Health 2002. 2011;20:1729–35. intrauterine system with the etonogestrel subdermal implant. Fertil Steril. 107. Ruminjo JK, Sekadde-Kigondu CB, Karanja JG, Rivera R, Nasution M, Nutley T. 2016;106:151–157.e5. Comparative acceptability of combined and progestin-only injectable 129. Bahamondes L, Brache V, Meirik O, Ali M, Habib N, Landoulsi S, et al. A contraceptives in Kenya. Contraception. 2005;72:138–45. 3-year multicentre randomized controlled trial of etonogestrel- and 108. Sivin I, Croxatto H, Bahamondes L, Brache V, Alvarez F, Massai R, et al. Two- levonorgestrel-releasing contraceptive implants, with non-randomized year performance of a Nestorone®-releasing contraceptive implant: a three- matched copper-intrauterine device controls. Hum Reprod. 2015;30: center study of 300 women. Contraception. 2004;69:137–44. 2527–38. Polis et al. Reproductive Health (2018) 15:114 Page 17 of 17

130. Diedrich JT, Madden T, Zhao Q, Peipert JF. Long-term utilization and 153. Mansour D, Bahamondes L, Critchley H, Darney P, Fraser IS. The management continuation of intrauterine devices. Am J Obstet Gynecol. 2015;213:822. e1–6 of unacceptable bleeding patterns in etonogestrel-releasing contraceptive 131. Rowe P, Farley T, Peregoudov A, Piaggio G, Boccard S, Landoulsi S, et al. implant users. Contraception. 2011;83:202–10. Safety and efficacy in parous women of a 52-mg levonorgestrel-medicated 154. Weisberg E, Hickey M, Palmer D, O’Connor V, Salamonsen LA, Findlay JK, et intrauterine device: a 7-year randomized comparative study with the al. A randomized controlled trial of treatment options for troublesome TCu380A. Contraception. 2016;93:498–506. uterine bleeding in Implanon users. Hum Reprod. 2009;24:1852–61. 132. Hubacher D, Masaba R, Manduku CK, Chen M, Veena V. The levonorgestrel 155. Friedlander E, Kaneshiro B. Therapeutic options for unscheduled bleeding intrauterine system: cohort study to assess satisfaction in a postpartum associated with long-acting reversible contraception. Obstet Gynecol Clin N population in Kenya. Contraception. 2015;91:295–300. Am. 2015;42:593–603. 133. Granzow K. The ‘nonmenstrual woman’ in the new millennium? Discourses 156. Rager KM, Fowler A, Omar HA. Successful treatment of depot on menstrual suppression in the first decade of extended cycle oral medroxyprogesterone acetate-related vaginal bleeding improves contraception use in Canada. Cult Health Sex. 2014;16:620–33. continuation rates in adolescents. ScientificWorldJournal. 2006;6:353–5. 134. Johnston-Robledo I, Ball M, Lauta K, Zekoll A. To bleed or not to bleed: 157. Sadeghi-Bazargani H, Ehdaeivand F, Arshi S, Eftekhar H, Sezavar H, Amanati young Women’s attitudes toward menstrual suppression. Women Health. L. Low-dose oral contraceptive to re-induce menstrual bleeding in 2003;38:59–75. amenorrheic women on DMPA treatment: a randomized clinical trial. Med 135. Repta R, Clarke LH. “Am I going to be natural or am I not?”: Canadian Sci Monit. 2006;12:CR420–5. Women’s perceptions and experiences of menstrual suppression. Sex Roles. 158. Schelar E, Polis CB, Essam T, Looker KJ, Bruni L, Chrisman CJ, et al. Multipurpose 2013;68:91–106. prevention technologies for sexual and reproductive health: mapping global 136. Rose JG, Chrisler JC, Couture S. Young Women’s attitudes toward needs for introduction of new preventive products. Contraception. 2016;93:32–43. continuous use of oral contraceptives: the effect of priming positive 159. Tolley EE, Morrow KM, Owen DH. Designing a multipurpose technology for attitudes toward menstruation on women’s willingness to suppress acceptability and adherence. Antivir Res. 2013;100:S54–9. menstruation. Health Care Women Int. 2008;29:688–701. 160. Bahamondes L, Brache V, Meirik O, Ali M, Habib N, Landoulsi S. A 3-year 137. Makuch MY, Osis MJD, Petta CA, de Pádua KS, Bahamondes L. Menstrual multicentre randomized controlled trial of etonogestrel- and levonorgestrel- bleeding: perspective of Brazilian women. Contraception. 2011;84:622–7. releasing contraceptive implants, with non-randomized matched copper- 138. Sánchez-Borrego R, García-Calvo C. Spanish women’sattitudestowards intrauterine device controls. Hum Reprod. 2015;30:2527–38. menstruation and use of a continuous, daily use hormonal combined contraceptive regimen. Contraception. 2008;77:114–7. 139. Gunson JS. “More natural but less normal”: reconsidering medicalisation and agency through women’s accounts of menstrual suppression. Soc Sci Med. 2010;71:1324–31. 140. Szarewski A, Moeller C. Women’s perceptions about reducing the frequency of monthly bleeding: results from a multinational survey. Open Access J Contracept. 2013;2013:29–37. 141. Greig AJ, Palmer MA, Chepulis LM. Hormonal contraceptive practices in young Australian women (⩽25 years) and their possible impact on menstrual frequency and iron requirements. Sex Reprod Healthc. 2010;1:99–103. 142. Kuhlmann AS, Henry K, Wall LL. Menstrual hygiene Management in Resource-Poor Countries. Obstet Gynecol Surv. 2017;72:356–76. 143. Curtis KM, Jatlaoui TC, Tepper NK, et al. U.S. Selected Practice Recommendations for Contraceptive Use, 2016. MMWR Recomm Rep. 2016; 65:1–66. 144. World Health Organization, K4Health, editors. Family planning: a global handbook for providers: evidence-based guidance developed through worldwide collaboration. [Geneva]: Baltimore: World Health Organization, Department of Reproductive Health and Research; John Hopkins Bloomberg School of Public Health, Center for Communication programs, Knowledge for Health Project; 2011. 145. Backman T, Huhtala S, Luoto R, Tuominen J, Rauramo I, Koskenvuo M. Advance information improves user satisfaction with the levonorgestrel intrauterine system. Obstet Gynecol. 2002;99:608–13. 146. Higgins JA, Smith NK. The sexual acceptability of contraception: reviewing the literature and building a new concept. J Sex Res. 2016;53:417–56. 147. Jain A, Reichenback L, Ehsan I, Rob U. "Side effects affected my daily activities a lot": a qualitative exploration of the impact of contraceptive side effects in Bangladesh. Open Access J Contracept. 2017;8:45-52. 148. Belsey EM, Machin D, d’Arcangues C. The analysis of vaginal bleeding patterns induced by fertility regulating methods. Contraception. 1986;34:253–60. 149. Halpern V, Lopez LM, Grimes DA, Stockton LL, Gallo MF. Strategies to improve adherence and acceptability of hormonal methods of contraception. Cochrane Database of Syst Rev. 2013, Issue 10. Art. No.: CD004317. https://doi.org/10.1002/14651858.CD004317.pub4.. 150. Villavicencio J, Allen R. Unscheduled bleeding and contraceptive choice: increasing satisfaction and continuation rates. Open Access J Contracept. 2016;7:43. 151. Darney PD, Stuart GS, Thomas MA, Cwiak C, Olariu A, Creinin MD. Amenorrhea rates and predictors during 1 year of levonorgestrel 52 mg intrauterine system use. Contraception. 2018;97:210-14. 152. Abdel-AleemH, d’Arcangues C, Vogelsong KM, Gaffield ML, Gülmezoglu AM. Treatment of vaginal bleeding irregularities induced by progestin only contraceptives. Cochrane Database Syst Rev. 2013. Issue 10. Art. No.: CD003449. https://doi.org/10.1002/14651858.CD003449.pub5.